Clinical and Health Affairs
The Minnesota Diabetes Plan 2015
Stemming the Tide on an Epidemic and Improving Patient Care
By Audrey Weymiller, Ph.D., C.N.P., Gregg Simonson, Ph.D., Mark Liebow, M.D., Kim Goodwin, M.P.A., and Gretchen Taylor, M.P.H., R.D.
■ The Minnesota Diabetes Steering Committee, a group of experts in diabetes care and prevention from around the state, in collaboration with the Minnesota Department of Health, is working to slow the incidence of diabetes and improve the care of Minnesotans who have the disease. The steering committee has developed a new five-year diabetes plan for the state that identifies nine areas around which stakeholders will focus energy and take action. This article describes that plan.
The news about the prevalence of diabetes in this country is sobering. One in three Americans born in the year 2000 will develop some form of the disease during their lifetime if current trends continue. For black and Hispanic children, the risk of developing diabetes is nearly one in two.1 The prevalence of diabetes in the adult population in the United States is expected to increase 165% by 2050 (it rose 49% between 1990 and 2000). Already, 1.5 million adults (more than one in three) in Minnesota have diabetes or prediabetes, according to Minnesota Department of Health estimates.2 Every year, 20,000 Minnesotans are diagnosed with the disease. The impact of diabetes is tremendous. It is the sixth leading cause of death in Minnesota, and those living with the disease have a lower quality of life. Because diabetes can affect nearly every organ system, people with diabetes have higher rates of heart disease and stroke, depression, arthritis, blindness, kidney disease, and even infectious diseases. It is the leading cause of blindness, renal failure, and nontraumatic amputation in Minnesota.2
In addition to its toll on individual health, diabetes has an economic impact. People with the disease can expect to earn one-third less in their lifetime as a result of having it.3 Because of often-preventable sick days and medical complications associated with diabetes, society as a whole also feels the effect, as it pays the cost of lost productivity and of treatment for a large number of people who have the disease. The American Diabetes Association estimates the total cost of diabetes in 2007 was $174 billion.4 In Minnesota, diabetes costs an estimated $2.68 billion per year; about $1 billion of that is the result of lost productivity.2
2015 Focus Areas
The Minnesota Diabetes Plan 2015 identifies the following areas around which coordinated action will be needed in the coming years:
- Increasing access to clinic and hospital care, especially among people with low incomes and populations of color;
- Increasing accountability among providers and health systems for identifying and referring patients to community-based health resources;
- Increasing care coordination between clinics and hospitals, between primary care providers and specialists, and between primary care and community-based health resources;
- Developing and/or increasing the availability of community health resources for diabetes prevention and management for adults older than 60, new immigrants, and people of color; Developing messages and methods to increase patients’ knowledge and skills in diabetes self-management;
- Increasing the number of organizations offering lifestyle-related diabetes prevention programs statewide, specifically to underserved populations;
- Improving healthy behaviors and achieving diabetes self-management goals for women with or at risk for gestational diabetes;
- Incorporating healthful eating and nutrition education into school curricula and establishing policies in child-care and school settings; and
- Increasing access to affordable and healthful food in underserved communities.
We’ve known for some time that the impact of diabetes is distributed unevenly across ethnic, socioeconomic, and age groups. Those most affected by premature onset of diabetes and its complications include certain ethnic minorities, people with lower socioeconomic status, and older adults.5
Various social determinants of health have an effect on both the prevalence and treatment of the disease. A recent study showed the disparity in diabetes-related mortality across education levels grew from the late 1980s to 2005 overall and among men, women, blacks, whites, and Hispanics.6 MN Community Measurement data show that Minnesotans who have government-sponsored health insurance do not receive the same quality of diabetes care as patients with private insurance when treated by the same health care providers.7
Diabetes does not have to exact this great a toll. We know type 2 diabetes can be delayed or prevented if individuals make modest lifestyle changes. In the Diabetes Prevention Program, a major multicenter clinical research study, conversion to diabetes was reduced by 58% over a three-year period among people with prediabetes who achieved modest weight loss (7% of body weight) and increased their physical activity to 150 minutes a week. Study participants 60 years of age and older reduced their risk by 71%.8 That study also showed that taking oral metformin can delay the onset of type 2 diabetes, although it is not as effective as making lifestyle changes. Participants in the group that received metformin reduced their risk of developing diabetes by 31% as compared with the group that received a placebo.8
In addition to studies showing that type 2 diabetes can be prevented, evidence about how best to help patients manage their disease is growing. Yet, although many aspects of optimal diabetes care have been defined, consistent high-quality diabetes care is not always delivered. In Minnesota, for example, only 25% of patients on average achieve the five goals that have the greatest impact on decreasing cardiovascular complications associated with diabetes.7
These include having blood pressure less than 140/90 mmHg, a low-density lipoprotein level of less than 100 mg/dL, a hemoglobin A1c less than 8, not smoking, and taking a low dose of aspirin, if appropriate.9
Indeed, the potential to make improvements in both the prevention and management of the disease is great.10
Minnesota Diabetes Plan 2015
Preventing diabetes as well as improving treatment for people who have the disease are the goals of the Minnesota Department of Health’s diabetes program. In 1981, the Department of Health convened the Minnesota Diabetes Steering Committee to advise the diabetes program. Its members represented medical, professional, and volunteer groups with a strong interest in diabetes. Since then, the committee has provided the vision and direction for reducing the impact of diabetes in the state and has used its influence to advocate for action and policy change to make that happen.
One mechanism the steering committee has used to accomplish its mission has been the Minnesota Diabetes Plan. It updates the plan every five to 10 years. Among the accomplishments that can be attributed to the state plan are the standardization of diabetes care and related quality measures used in the state, the development of a diabetes guide for long-term care settings, institution of an annual health disparities conference for safety-net providers, reversal of the loss of MinnesotaCare coverage for people with diabetes, and dramatic reductions in the rates of certain complications such as lower-extremity amputations. The state’s 2000 plan identified the need for adequate insurance coverage for people with diabetes. Subsequent advocacy efforts resulted in passage of the Diabetes Cost Reduction Act in Minnesota. This legislation standardized coverage for people with diabetes and was later replicated in 46 states.
Generally, the state’s diabetes plan has articulated a high-level vision and a blueprint for achieving it. This year, the Minnesota Diabetes Steering Committee sought to address the epidemic of diabetes in a more concrete and comprehensive way. Committee members first identified a long list of potential areas where the diabetes community in Minnesota could expend dollars and effort, then winnowed that list down to the nine they felt might be the most realistic and effective (see “2015 Focus Areas”). Teams are now being formed to work on each of these.
A Role for Physicians
Physicians have always played a leadership role on the Minnesota Diabetes Steering Committee and in designing and implementing the state’s diabetes plan. Physicians
Minnesota Diabetes Steering Committee Leadership Team
|Audrey Weymiller, Ph.D., CNP, Mayo Clinic, chair
Gregg Simonson, Ph.D., International Diabetes Center, immediate past chair
Pat Adams, M.P.H., R.N., Office of Statewide Health Improvement Initiatives, Minnesota Department of Health
Robert Albee, A Partnership of Diabetics
Macaran A. Baird, M.D., Department of Family Medicine and Community Health, University of Minnesota
Carol Lange, M.P.H., Department of Family Medicine and Community Health, University of Minnesota
Don Bishop, Ph.D., Center for Health Promotion, Minnesota Department of Health
Marit Hansen, Novo Nordisk, Inc.
Sheila Kiscaden, Decade of Discovery: A Minnesota Partnership to Conquer Diabetes
|Carol Manchester, M.S.N., A.P.R.N., A.C.N.S., University of Minnesota Medical Center
Jim McGowan, American Diabetes Association
Connie Norman, Native American Community Clinic
Teresa L. Pearson, M.S., R.N., Halleland Habicht Health Care Consulting, LLC
Rosemarie Rodriguez-Hager, Office of Minority and Multicultural Health, Minnesota Department of Health
Chris Schaeffer, American Diabetes Association–Minnesota
Bill Tendle, Southside Community Health Services
Sarah M. Westberg, Pharm.D., Pharmaceutical Care and Health Systems, University of Minnesota College of Pharmacy
Staff support provided by Gretchen Taylor, Kim Goodwin, Rita Mays, and Laurel Reger of the Minnesota Diabetes Program, Minnesota Department of Health.
again participated in the development of the Minnesota Diabetes Plan 2015. The committee’s physician members brought their unique perspective to the table as they discussed areas of need and set priorities. Among the concerns they raised were the need to identify the components of diabetes care that are best done in medical homes, improve hospital discharge summaries for people with diabetes, improve communication between primary care providers and subspecialists when they share the care of a patient with diabetes, and develop comprehensive up-to-date lists of community resources for people with prediabetes and diabetes. Those issues were incorporated into the plan. Physicians’ voices are now needed as groups are forming to determine how to best make progress in each of the nine areas.
The Minnesota Diabetes Plan 2015 urges everyone in the state to play a part in reducing the burden of diabetes, as achieving this goal will require a unified effort on many fronts. Physicians, as practitioners, researchers, community leaders, and educators, are encouraged to get involved in one of the nine action groups. To do so, contact Minnesota Diabetes Steering Committee Chair Audrey Weymiller, Ph.D., at email@example.com or Gretchen Taylor, diabetes program supervisor for the Minnesota Department of Health at firstname.lastname@example.org or 651/201-5390. MM
Audrey Weymiller is chair of the Minnesota Diabetes Steering Committee and a clinical nurse researcher and nurse practitioner at Mayo Clinic. Gregg Simonson is immediate past-chair of the steering committee and leads professional and industry educational programs at the International Diabetes Center. Mark Liebow is a consultant in internal medicine at Mayo Clinic. Kim Goodwin is plan coordinator and Gretchen Taylor is supervisor for the diabetes program at the Minnesota Department of Health.
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10. Agency for Healthcare Research and Quality. Making the Case for Diabetes Quality Improvement. Available at: www.ahrq.gov/qual/diabqual/diabqguidemod1.htm. Accessed July 18, 2011.